A pilot study of falls, fear of falling, activity levels and fall prevention actions in older people with polio

Femoral Shaft Fracture in Post-polio Syndrome Patients: Case Series from a Level-I Trauma Center and Review of Literature

BACKGROUND

Femoral shaft fracture in patients of post-polio syndrome (PPS) represents an uncommon yet complex injury pattern. Poorly developed soft-tissue envelope, decreased muscle bulk, reduced vascularity, regional osteopenia, joint contractures, and altered bony anatomy impose significant surgical challenges. Thorough pre-operative planning is imperative as each case requires individualized approach and method of fixation. The aim of the study was to analyze the clinical outcomes in such patients following fracture fixation and to assess the surgical challenges encountered and provide solutions.

MATERIALS AND METHODS

A retrospective case series of 33 patients with femoral shaft fracture in PPS limbs was undertaken. Mode of injury, method of fixation, surgical time, intra-operative blood loss, union time, and complications were recorded.

RESULTS

Low-energy fall was the most common mechanism of injury (73%). Thirty-three patients underwent fixation with intramedullary nailing being the most common mode (79%). Femoral canal diameter, femoral bow, fracture location and morphology and clinical deformities of the patients are key governing factors that determine the choice of implant. Locking plates, pre-contoured anatomical plates, and titanium elastic nailing system offer an alternative in patients unsuitable for nailing. With no difference between various implants, average time for bone healing was 13.8 ± 4.4 weeks. All patients resumed full weight-bearing mobilization and returned to pre-injury activity status at the end of 6 months post-surgery.

CONCLUSION

With detailed pre-operative work-up, contemplating intra-operative difficulties, individualized surgical plan, careful handling of soft tissues, and availability of back-up implants, good clinical outcomes can be achieved in femur fractures in PPS patients.

Outcomes of dual mobility articulation total hip arthroplasty in ipsilateral residual poliomyelitis

BACKGROUND

Patients with poliomyelitis underwent total hip arthroplasty (THA) are known to be at higher risk of dislocation on account of muscular atrophy. This study aimed to investigate clinical outcomes, radiographic outcomes, complication rates, and survivorship of dual mobility THA in displaced femoral neck fractures of elderly with poliomyelitis.

MATERIALS AND METHODS

We retrospectively included 17 patients (17 hips) with residual poliomyelitis who underwent THA with dual mobility articulation. Clinical outcomes were assessed with the visual analog scale (VAS) pain score, Oxford hip score, and University of California Los Angeles activity (UCLA) score. Radiographic outcomes were examined by radiographs. Complications and re-operations following THA were recorded.

RESULTS

The mean follow-up period was 77.05 months. The mean VAS, Oxford hip score, and UCLA score were improved significantly. In all but one patient, no complications were occurred. Re-operation was carried out in one patient due to posterior dislocation. The Kaplan-Meier survivorship with an end point of re-operation for any reason was 94.1%.

CONCLUSIONS

THA with dual mobility system is proved to be effective in strengthening stability and reducing the risk of dislocation, which is suitable for patients with neuromuscular disease. Hence, in elderly with residual poliomyelitis, dual mobility THA is a valid choice as a treatment for displaced femoral neck fractures.

Factors associated with falls in Japanese polio survivors

Purpose: To identify factors associated with falls in Japanese polio survivors and assess the extent of their impact.Materials and methods: Subjects were 128 polio survivors. Fall history and fear of falling, lower limb muscle strength, gait ability (determined by walking speed and number of steps per day), post-polio syndrome incidence, and orthosis or walking aid use were assessed, and factors associated with falls were identified using logistic regression analysis.Results: The fall rate was 64%. Fallers (subjects with one or more falls in the preceding 12 months) had low lower limb muscle strength, slow walking speed, high total scores on the Fall Efficacy Scale-International, which assesses fear of falling, and a high orthosis use rate. Knee extension muscle strength on the weaker side was identified as a main factor influencing risk of falls (odds ratio: 0.72, 95% confidence interval: 0.56-0.96). Receiver operating characteristic curve analysis gave a cutoff value for knee extension muscle strength on the weaker side of 0.42 N/kg or lower.Conclusion: Low knee extension muscle strength on the weaker side was associated with falls, but predictive ability using a single internal factor might be poor. It appears that a comprehensive examination, including other factors, is required.Implications for rehabilitationAs polio survivors age, their risk of falling increases.To identify polio survivors who are at risk of falls, it is important to determine the factors associated with falls and their influence on fall risk.The results of this study showed that reduced knee extension muscle strength on the weaker side was a risk factor for falls in polio survivors.To precisely predict the risk of falls in polio survivors, a comprehensive evaluation of both internal and external factors is required.

Poliomyelitis

Poliomyelitis, often termed "polio," is an acute infectious disease caused by an enterovirus which damages the anterior horn cells of the spinal cord and brainstem. Progress to lower motor neurone cell death leads to disruption of motor units and subsequent muscle weakness or complete paralysis. Although the virus is mostly eradicated from the Western world, postpolio decline is prevalent among people aged 60 years and over. It is characterized primarily by fatigability and muscle weakness, but pain is also common. Reductions in lower-limb muscle strength, voluntary drive, and endurance are likely to contribute to the impaired balance control, slow gait, and dysfunctional lower-limb kinematics reported in polio survivors. Given these significant risk factors, polio survivors fall up to four times more often than their age-matched healthy peers. Interventions to improve function, reduce disability, and prevent falls in polio survivors are therefore clinically relevant but studies are lacking, limiting the evidence base. Balance training, cognitive behavioral therapy, and orthoses prescription might be recommended. Muscle-strengthening programs should be carefully designed and delivered due to their potential detrimental effects related to excessive use and potential dysfunction of motor neurones and their axons.

Reverse Less Invasive Stabilization System (LISS) Plating for Proximal Femur Fractures in Poliomyelitis Survivors: A Report of Two Cases

Case series

Patient: Female, 50 • Male, 60

Final Diagnosis: Proximal femur fractures

Symptoms: Hip pain

Medication: —

Clinical Procedure: Internal fixation surgery

Specialty: Orthopedics and Traumatology

Relationship of depression and medications on incidence of falls among people with late effects of polio

The purpose of this study was to determine if falls in polio survivors, with or without post-polio syndrome (PPS), are related to number of medications taken, use of anti-depressant or psychoactive medications, or self-report of depression. A survey was sent to 300 members of a regional polio support group, asking them to document their fall history, medications used, and the presence of depression. Depression was measured by self-report and with the Geriatric Depression Scale, short form (GDS-15). One hundred and seventy-two usable surveys were returned with 146 of those completing the medication list. Sixty-two percent reported at least one fall in the past year. The multiple logistic regression was significant (p = 0.023), and it indicated depression to be a significant predictor (p = 0.012) of falls in polio survivors with and without PPS. The number of total medications or anti-depressant or psychoactive medications used was not related to fall incidence. Routine screening and treatment for depression may be one aspect of fall prevention which can be implemented through primary care.

Correlates of cognitive functioning in independent elderly patients discharged home from the emergency department after a minor injury

BACKGROUND

The objective of this study was to explore correlates of cognitive functioning of older adults visiting the emergency department (ED) after a minor injury.

METHODS

These results are derived from a large prospective study in three Canadian EDs. Participants were aged ≥ 65 years and independent in basic activities of daily living, visiting the ED for minor injuries and discharged home within 48 hours (those with known dementia, confusion, and delirium were excluded). They completed the Montreal Cognitive Assessment (MoCA). Potential correlates included sociodemographic and injury variables, and measures of psychological and physical health, social support, mobility, falls, and functional status.

RESULTS

Multivariate analyses revealed that male sex, age ≥ 85 years, higher depression scores, slower walking speed, and self-reported memory problems were significantly associated with lower baseline MoCA scores.

CONCLUSIONS

These characteristics could help ED professionals identify patients who might need additional cognitive evaluations or follow-ups after their passage through the ED. Obtaining information on these characteristics is potentially feasible in the ED context and could help professionals alter favorably elderly's trajectory of care. Since a significant proportion of elderly patients consulting at an ED have cognitive impairment, the ED is an opportunity to prevent functional and cognitive decline.

Falls in Korean Polio Survivors: Incidence, Consequences, and Risk Factors

Falls and fall-related injuries are important issue among polio survivors. The purpose of this study was to determine the incidence of, and consequences and factors associated with falls among Korean polio survivors. A total of 317 polio survivors participated in this study. All participants completed a questionnaire including fall history, symptoms related to post-polio syndrome and other information through a telephone interview. Among them, 80 participants visited our clinic for additional physical measurements and tests. Of the 317 respondents, 68.5% reported at least one fall in the past year. Of the fallers, 42.5% experienced at least one fall during one month. Most falls occurred during ambulation (76.6%), outside (75.2%) and by slipping down (29.7%). Of fallers, 45% reported any injuries caused by falls, and 23.3% reported fractures specifically. Female sex, old age, low bone mineral density, the presence of symptoms related to post-polio syndrome (PPS), poor balance confidence, short physical performance battery and weak muscle strength of knee extensor were not significantly associated with falls. Only leg-length discrepancy using spine-malleolar distance (SMD) was a significant factor associated with falls among Korean polio survivors. Our findings suggest that malalignment between the paralytic and non-paralytic limb length should be addressed in polio survivors for preventing falls.

Perceived cause, environmental factors, and consequences of falls in adults with cerebral palsy: a preliminary mixed methods study

Objective. Describe perceived cause, environmental influences, and consequences of falls or near-falls in ambulant adults with cerebral palsy (CP). Methods. Adults with CP completed postal surveys and follow-up semistructured interviews. Surveys sought information on demographic data, self-nominated Gross Motor Function Classification Score (GMFCS-E&R), falls, and near-falls. Interviews gathered additional information on falls experiences, near-falls, and physical and psychosocial consequences. Results. Thirty-four adults with CP participated. Thirty-three participants reported at least one fall in the previous year. Twenty-six participants reported near-falls. Most commonly, falls occurred indoors, at home, and whilst engaged in nonhazardous ambulation. Adults with CP experienced adverse falls consequences, lower limb injuries predominant (37%), and descriptions of fear, embarrassment, powerlessness, and isolation. Discussion. Adults with CP may experience injurious falls. Further investigation into the impact of falls on health-related quality of life and effective remediation strategies is warranted to provide comprehensive falls prevention programs for this population.

Outcome expectations and physical activity in persons with longstanding multiple sclerosis

Research suggests that persons with multiple sclerosis (MS) are much less physically active than the general population and that increased physical activity in persons with MS is associated with numerous benefits such as improvements in fatigue, mobility, and quality of life (). Potentially modifiable theory-based determinants of physical activity behavior need to be identified so that researchers may study their effectiveness in randomized clinical trials and clinicians may integrate them into practice to promote physical activity in this population. The purpose of this study was to explore the multidimensional (physical, social, and self-evaluative) outcome expectations for physical activity among persons with longstanding MS. A sample of 369 participants diagnosed with MS for more than 15 years completed surveys to measure multidimensional outcome expectations for exercise, MS functional limitations, and physical activity using two different instruments: one measuring physical activity engagement and the other measuring physical activity capability. Results indicated that MS functional limitation was the strongest predictor of both physical activity engagement and physical activity capability. Physical and social outcome expectations contributed to the model explaining 12% of the variation in physical activity engagement, whereas none of the outcome expectancy dimensions (physical, social, or self-evaluative) contributed to the model explaining variation in physical activity capability. Although analyses of cross-sectional data do not infer causation, these findings suggest that positive physical and social outcome expectations for physical activity are associated with engagement in physical activity as well as being potential sources of motivation for increasing physical activity behavior in individuals living with longstanding MS.

Distal femoral fractures in post-poliomyelitis patients treated with locking compression plates

OBJECTIVE

Treatment of distal femoral fracture in post-polio patients is difficult because the bone is usually osteopenic, small and deformed. This retrospective study aimed to investigate the outcomes of distal femoral fracture in post-polio patients treated by locking compression plates (LCP).

METHODS

The medical records of 19 post-polio patients (mean age 49 years at time of surgery) were reviewed and intraoperative data retrieved. Fracture union and callus formation were evaluated on radiographs taken at each postoperative visit. Functional outcome assessments included range of motion and Hospital for Special Surgery (HSS) score of the ipsilateral knee joint.

RESULTS

Sixteen femoral fractures occurred in the poliomyelitis-affected limbs. The mean duration of operation was 86 min and mean blood loss 120 mL. All fractures healed (mean, four months) but union was delayed in one. At the final follow-up 2 yrs after surgery, the mean range of knee flexion was 105° (range, 90°-130°), and mean HSS score 76 points (range, 60-93). There were no cases of nonunion, implant cutout, or other complications.

CONCLUSIONS

LCP provides stable fixation of distal femoral fractures in post-polio patients. Bony union and good functional outcomes are achieved, but delayed union and minimal callus may occur.

Incidence, risk factors and consequences of falling injuries among the community-dwelling elderly in Shihpai, Taiwan

BACKGROUND AND AIMS

Falls causing injuries among older people and the consequences of those injuries are of increasing concern to public health practitioners. The aims of this study were to determine the incidence, characteristics and risk factors of fall injuries among the community-dwelling elderly in Shihpai, Taiwan; the impact on quality of life and health service utilization was also comprehensively studied.

METHODS

1361 community-dwelling elderly who had been enrolled in the Shihpai eye study (1999-2000) were included. Subjects were interviewed and examined by trained interviewers, and data such as demographics, medical conditions, blood pressure, ophthalmic examination, fall history and quality of life (SF-36) were collected. Chi-square tests, analyses of covariance and multiple logistic regressions were performed as the main statistical methods.

RESULTS

The mean age of the participants was 72.2 (range, 65-91) years old. 16.3% of the elderly persons interviewed had experienced at least one fall; among those, up to 50% had suffered mild injuries, and the incidence of remarkable injury was 27.6%. There were no significant differences in the location or time of falling, but there were different risk factors and consequences in injury severity. Fallers with remarkable injuries had a higher incidence of hospitalization and a greater fear of falling. No statistically significant decline in quality of life with increasing severity of falling injury was identified after a 12-month follow-up period.

CONCLUSIONS

Gender, visual impairment and orthostatic hypotension were identified as the major risk factors of fall injuries in the elderly. These factors should be emphasized in order to reduce fall injuries in geriatrics.

A systematic review of the Human Activity Profile

OBJECTIVE

To review the measurement properties (reliability, validity, responsiveness) of the Human Activity Profile (HAP), a self-report measure of energy expenditure or physical fitness.

DATA SOURCES

MEDLINE, CINAHL and EMBASE were searched up to September 2005 and the reference lists of included studies were checked for additional relevant studies.

REVIEW METHOD

Studies were included that reported Human Activity Profile scores, test-retest reliability, correlations with other measures, or responsiveness (sensitivity to change). Of 83 potentially relevant articles, 39 articles were included plus the test manual. Two independent reviewers extracted data from the included studies.

RESULTS

The Human Activity Profile has been used to evaluate physical activity in a wide variety of clinical populations and in healthy individuals. The change in score required to be 90% confident that change is beyond measurement error was estimated to be 7.8 for the Maximum Activity Score and 6.8 for the Adjusted Activity Score. The construct validity of the Human Activity Profile was supported by a large number of studies, although evidence for criterion validity was limited to four studies. No studies have investigated a priori the responsiveness or minimum clinically important difference of the Human Activity Profile.

CONCLUSION

The Human Activity Profile appears to be a useful indicator of physical activity levels in people with chronic pain, arthritis, renal failure, various neurological and cardiorespiratory conditions, as well as in healthy older people.

Anxiety symptoms and decline in physical function over 5 years in the health, aging and body composition study

OBJECTIVES

To examine the relationship between anxiety and functional decline.

DESIGN

A 5-year longitudinal cohort study of well-functioning adults.

SETTING

The Health, Aging and Body Composition (Health ABC) Study.

PARTICIPANTS

Two thousand nine hundred forty adults aged 70 to 79 (48% male, 41% black), initially free of self-reported mobility difficulty.

MEASUREMENTS

In 1997/98, presence of three anxiety symptoms (feeling fearful, tense or keyed up, or shaky or nervous) from the Hopkins Symptom Checklist were ascertained. Physical function was examined over 5 years using the Health ABC performance battery (continuous range 0-4) consisting of chair stands, usual and narrow course gait speed, and difficulty with standing balance and self-reported mobility, defined as difficulty walking one-quarter of a mile or difficulty climbing 10 steps.

RESULTS

Participants with anxiety symptoms had similar baseline physical performance scores. After adjustment for potential confounders, subjects with anxiety symptoms had similar declines in physical performance over 5 years as participants without anxiety symptoms. Adults with anxiety symptoms were more likely to report incident mobility difficulty, with a hazard ratio of 1.4 (95% confidence interval=1.3-1.6), compared with adults without anxiety symptoms. These results persisted after adjustment for depressive symptoms, demographics, comorbidity, and use of antianxiety, depressant, and sedative hypnotic medications.

CONCLUSION

Anxiety symptoms are not associated with declines in objectively measured physical performance over 5 years but are associated with declines in self-reported functioning. Future studies are needed to determine why anxiety has a differential effect on performance-based and self-reported measures of functioning.